Performance improvement

"Anyone who has never made a mistake has never tried anything new."

—Albert Einstein

This is the story of a team that never failed a test of change. No matter what the team members did, rapid improvement cycle after rapid improvement cycle, every small test tried was a better jewel than the one before. They received an A for their PDSAs.

They were fearless—in their imaginations. The only problem with the team’s brilliant tests of change was that they never got tested, never got to the stage where stumbling or failed ideas might have real consequences. There was no learning, no innovation, no growth—just intriguing ideas that remained bottled.

In health care, it’s still frowned upon to talk about failures or things that don’t work out perfectly for fear the information will be used against the people involved. But even in a high-stakes industry where the consequence of some decisions means life or death, there is plenty of room for improving performance by learning from small failures.

Using small failures as learning opportunities is the cornerstone of creating a learning organization. Small failures are at the heart of the Rapid Improvement Model and its plan, do, study, act cycles.

“Despite the increased rate of failure that accompanies deliberate experimentation, organizations that experiment effectively…are likely to be more innovative, productive and successful,” writes Amy Edmondson, a professor at Harvard Business School, in a December 2004 article in the Quality and Safety in Healthcare Journal.

This in fact is a story of false starts: the story of unit-based teams and employees throughout Kaiser Permanente who already are learning, developing and innovating from missteps or downright unsuccessful small tests of change.

From projects that changed direction after data contradicted the original premise, to tests of change that were tweaked or abandoned all together, workers describe how they tried a small improvement that didn't turn out as expected and still gained from the experience. And even, eventually, found success.

Learning to fail

At San Diego Medical Center’s Nuclear Medicine department, the unit-based team decided its first test of change project would look at reducing the number of redundant heart scans, which technologists were certain were wasting time and resources.

In November 2009, team members began to track the number of repeat scans to establish a baseline. They figured repeats would be at least 25 percent of the heart scans. After a month of logging the scans, however, they discovered something quite different.

“The number of repeat heart scans was actually between 7 to 10 percent,” says the UBT’s labor co-lead, Jessica Larson, a tech assistant and OPEIU Local 30 member.

The team’s hypothesis was amiss. It switched gears.

Since several of the staff recommendations for test of change projects related to heart scans, the team focused next on the variation in the instructions patients were given. If team members gave identical instructions, they might be able to all but eliminate repeat heart scans.

“The test of change at that point was to make sure everyone was following the protocol,” says Randy Andres, a nuclear medicine technologist and OPEIU Local 30 member.

The team created laminated handouts with one set of clear instructions that technologists and receptionists were to hand out to every patient before a scan.

“We did that for a few weeks, and found it was a lot more complicated than we anticipated,” Larson says. “You had inpatients, outpatients, observation-unit patients….Forms were getting misplaced because patients would leave them in the waiting rooms or in their purse. Or people weren’t even giving them out.”

During the same time, a supply shortage meant the department had to switch the type of injectable radioactive isotope it was using. The change meant a whole new set of protocols. Compounding it all, the department’s longtime manager retired.

It was time to shelve the test of change.

But was it a waste of time? Not at all, say Larson and Andres. Both say it provided valuable information about the department’s work flow—as well as practical knowledge of how to conduct tests of change.

“This was a very good teaching experience for us,” Andres says. “We didn’t even know about tests of change before this. It’s not simply a matter of just changing something. You have to go through this process.”

Too much of a good thing

Further north at Redwood City Medical Center, the Gastroenterology department discovered you can have too much of a good thing.

Contracting with an Oregon company that specializes in mass outreach calls, the department began using automatic robocalls to reach patients ages 50 to 75 who were due or overdue for colorectal screenings.

“We had to think outside the box,” says Julie Dalcin, director of medicine. “This was a way to reach a lot of people.”

The first round of robocalls went out in November 2009, with some 10,000 calls made. They reached 97 percent of the members who were due for the tests—but there was a problem. The calls were made within a span of three hours, and the response overwhelmed the department and the facility. The voicemail box the team had set up in advance barely helped; it could take only 50 messages.

“We got bombarded by calls from patients calling back with questions or requests. Our operator was inundated,” says manager Isabel Uibel. “Physicians in other departments were also bombarded with calls. People…were like, ‘What’s going on?’”

Michele Coons, a medical assistant and SEIU UHW member, was devoted to returning the calls and to mailing “FIT kits,” the at-home stool tests that help detect early signs of colorectal cancer, to those who had requested them.

“Many people had a lot of questions,” Coons says. “‘Why did I get this call?’ ‘What does a FIT kit test mean?’”

It took a week to figure out a system for getting back to all the patients, she says.

“I think at the end of day you have to be willing to try,” Uibel says. “And forgive yourself for the time you put into something that didn’t work. And don’t lose motivation. But also know when…you’ve got to say, ‘We’re not going down the right path at all.’”

In some workplaces, what had happened would be labeled a disaster. But not in Redwood City. The essential idea was sound. For the second round of calls, the team addressed the overwhelming response by having the calls made over a two-week period.

“We didn’t think we needed to throw the baby out with the bathwater,” Uibel says. “We just had to keep tweaking to make the system work for us.”

Too good to be true

When it came to how quickly patient messages are responded to, the Internal Medicine at the East Denver Medical Office in Colorado was pretty close to bottom—only 8 percent of patient advice calls were answered within an hour. The team members were open to trying anything, and after several small tests of change, they hit on something so ridiculously simple that some people resisted it.

Nurses tape neon orange cards with the patient message to the door of the exam room where the doctor is working. The doctor sees the message on the way out of the room and goes back to his or her office to respond.

Within the first three months of the test, the department saw message turnaround times soar to 30 percent answered within the hour.

“You had some tangible symbol that you were trying to make these numbers move. It was a great motivator,” says Christopher Hicks, MD, the team’s physician co-lead. “It was different. It wasn’t something that was happening electronically.”

Then they hit a wall.

“We were sitting around threshold or target and then would drop back down,” explains Olivia Wright, supervisor and management co-lead. “We were just hovering around 20 to 30 percent.”

The team brainstormed about why it couldn’t move the number above 30 percent.

Someone suggested one reason could be that the call center opened at 7 a.m. and most of the staff didn’t start until 8 a.m. They were starting the day already behind the curve with waiting messages. Two nurses changed their schedule and started coming in at 7:30 a.m. That seemed to help: 52 percent of patient messages got a reply within an hour.

“You’ve got to give something a shot,” Wright says. “The first thing you come out of the gate with isn’t necessarily going to be the end-all be-all, but you’ve got to start somewhere.”

One of the most surprising lessons for the entire department was the fact that small changes could have such a large impact.

“There was a sense of disbelief,” Wright recalls. “We had to reassure the team that the volume of work hadn’t gone down or that it wasn’t because of the time of year. We’ve sustained these results since May, and it finally started to sink in that small, subtle changes really are the reason for these results.”

Failure is part of experimentation

Experts who study organizations like health care and the airline industry corroborate the importance the process of experimentation plays in organizational learning.

“Under conditions where there’s a lot of uncertainty and constantly moving parts and work is customized or unique, the only way to make it work is to allow the right level of leeway for teams…to experiment thoughtfully,” Edmondson says. In the long run, lasting success comes from a willingness to try new things; but, if you try new things, you're going to fail sometimes.

This isn’t license for projects based on haphazard hypotheses, but it underscores the fact that performance improvement methods such as the Rapid Improvement Model are made for small failures. Because the process allows for quick experimentation, with results evaluated within 30 to 60 days, there is little to lose.

Barbara Grimm, senior vice president of the Labor Management Partnership, would have people ask themselves a few questions that can help them weigh the possibility of failure.

“Have you reasoned through the consequences? That is key,” Grimm says. “Do you have the patient’s interest absolutely there? Do you have a plan if it doesn’t go well?”

Edmondson argues there are two key reasons health care organizations still resist learning from small failures: The culture often discourages questions, challenges, or admissions of error, and a demanding workload and pace force staff to rely on quick fixes when something doesn’t work, instead of systematic problem solving.

That is changing at Kaiser Permanente with the commitment to providing frontline staff with training and support to conduct root cause analysis and problem solving with RIM, RIM+ and other performance improvement tools. And unit-based teams give staff members the place and time to do this work.

John August, executive director of the Coalition of Kaiser Permanente Unions, believes the

true purpose of the Labor Management Partnership is to recognize the mission of KP and the mission of the unions are at profound risk due to the economic, competitive and public policy environment in which we operate.

“We must continually remind everyone in the organization that the why of what we do in partnership is driven by this fundamental recognition and agreement,” August says. “If we don’t make the effort to discuss the reasons why we’re doing this, people will get the impression that people are just being asked to do something. And being asked to do something doesn’t create an atmosphere of safety.”

Edmondson says the sense of safety will further develop when we learn to accept and work with our limitations.

“People need a sense of psychological safety, and frankly a sense of humor about our humanness,” Edmondson says. “Somewhere along the line we get socialized and begin to buy into the absurd notion that we should be perfect.”

Back at the lab

In San Diego, Larson thinks even if the tests of change didn’t work exactly as planned, it gave the team something even more important—the beginning of a different work culture.

“Being able to work on small tests of change enabled us to get past what’s always been,” Larson says. “There are people who have been here longer than I’ve been alive and so are accustomed to the way it was always done. But trying something new can save us time, and save the company money, and can be better for the patient. So I found it nice to look at it like, ‘Let’s try just this little thing and it might just make it better.’”

Larson is certain the eventual reward will outweigh any frustrations in wrong hypotheses or failed tests.

“Either you find you can fix something or you can’t, and you just move on,” Larson says. “Just keep trying. Because ultimately, it’s going to be a success in the end.”

Imagine developing a severe cough and teeth-chattering chills. You want to be seen by a doctor but no one really understands you: Not the call center operator with whom you try to make an appointment; not the receptionist who checks you in; not the medical assistant who takes your temperature and blood pressure. Not even the doctor who speaks quickly and uses complicated medical terms.

“When you come in for medical care, it’s already like a foreign land,” says Kathleen Kearney, the manager and the UBT co-lead for the Obstetrics and Gynecology department at San Jose Medical Center.  “If you don’t speak English, it can be downright frightening.”

Giving patients better access

Kaiser Permanente has long been committed to providing language access in the form of interpretive services for its non-English speaking members. The Ob/Gyn unit-based team in San Jose has taken the additional step of creating a Spanish-speaking module, a sort of one-stop shop for Spanish-speaking patients.

The idea for the module came from Joseph Derrough, MD, who recognized that good patient care involves more than just the patient and the physician in the exam room. It includes each interaction, from making an appointment to checking in and being assigned a room.

“I realized that we had a significant percentage of patients who only spoke Spanish, and we could do better service to them by providing linguistic and culturally competent care,” Dr. Derrough says. “We had staff that spoke Spanish, but they weren’t all in the same place. My vision was that we could create a clinic module where, from registration to examination, the patient was spoken to in her own language.”

Making it happen

The unit-based team made it happen.

“From the time they walk in the door, every patient should receive the same level of care regardless of the language they speak,” says Glenda Morrison, a medical assistant, SEIU UHW chief shop steward and the UBT co-lead.

But in the beginning, the frontline staff members, including Morrison, were skeptical.

“Since we were already serving Spanish-speaking patients in our clinic, the question we were asking was, ‘Why is this needed?’ ” Morrison says.

But a visit to the Spanish-speaking Medicine module at the Santa Clara campus made them believers. That module has been in place for five years.

“When I saw it in action, a light went off—and I realized that by not speaking to our Spanish-speaking members in their own language, we weren’t providing them with the same care as we were our English-speaking members,” Morrison says.

Overcoming obstacles

Once the team decided to take on the project, it faced some challenges. Offices had to be moved and medical assistants had to be reassigned.

“We had a lot of meetings and a lot of nervous people,” Morrison says.

But again, the Santa Clara example eased fears: “Once they saw how it worked in Santa Clara, we got by-in from the staff and it was easier,” Kearney says.

The module, which opened Sept. 29, includes signage and literature in Spanish. The staff members, from the receptionists and medical assistants to the doctors, are fluent Spanish speakers.  Word about the new module went out through Spanish-speaking television news and newspaper reports. And there was a grand opening.

It’s going well so far, Kearny says, noting that “we have three Spanish-speaking providers each day, and they have appointment capacity for about 20 patients.”

Next steps

Now, the team is looking for ways to quantify the benefits of the new module. It’s hoping to be able to collect patient satisfaction data specifically from Spanish-speaking members to assess the impact, Kearney says.

“If it shows success, we’ll pass the idea on to other teams,” she says.

Meanwhile, the unit is looking at how it can provide culturally competent care for its other monolingual patients.

“We don’t what a certain group to feel singled out,” Morrison says. “We just want them to feel comfortable.”

When you get to the leadership level it’s easy to become disconnected and to forget that where the rubber meets the road is at the front line. Sponsoring a unit-based team helps me stay connected—and that helps me be a better manager.

Staying connected

As a sponsor for the Medical Secretaries and Scanning Center, I help the teams see where they fit in the bigger picture—and they help me see the challenges that teams face every day.

I check in with the teams and their co-leaders regularly, make sure they’re accomplishing their goals and doing work that meets regional and national goals. They have their own ideas for improving department operations and doing their own small tests of change. I help them think strategically about how they can impact the region and Kaiser Permanente as a whole.  

There will always be the manager-employee relationship, but when you walk into a UBT meeting, you leave the hierarchy at the door. To build credibility, everyone on the UBT must have an equal voice at the table. I believe in the partnership and, yes, there are a few times when a manager shoulders the responsibility and has to make decisions about regulatory compliance issues, regional strategic direction and planning, scope of practice discussions about licensures and policies, and personnel management. But there are a lot of other decisions that staff can be a part of making in a group setting, and getting buy-in from the folks who do the work makes all the difference in the world.

Removing obstacles

Because I’m in a leadership role, it is important that I help the teams overcome barriers. If they need help understanding a goal, metric or budget, I can gather the information and package it in a way that is most helpful to the team.  When I started working with these teams in 2007, they were already doing good work despite some major obstacles. The chartroom transitioned to the scanning center, and the medical secretaries had a lot of manager and staff turnover, and had difficulty meeting performance metrics. Now both teams are high functioning. They have accomplished so much in the last two years.

So to other sponsors I say, don’t be afraid to jump in. It’s so rewarding to see your teams grow. If we are going to improve performance, we’ll need engagement at all levels of the organization, and the UBT process allows that to happen.

The employees in Charitable Health Coverage Operations (CHCO) felt good about their Northern California department’s mission—but not so good about how long it took sometimes to help the thousands of low-income children who benefit from KP-subsidized health care.

The department handles the eligibility paperwork for a KP program that provides health coverage to people who don’t qualify for employer-based health coverage or public programs like Medicaid. At the team’s low point in 2005, it had a six-month applications backlog.

“Our primary customers are children,” said Nancy Waring, CHCO customer care manager. “We have over 80,000 children, most of them low income. About 50 percent of our population is Spanish speaking. And the program is completely subsidized by Kaiser.”

Too large a group

In the past, one representative unit-based team encompassed the whole department.  Because employees within the same department were doing very different types of work—processing mail, entering data, processing enrollments, providing customer service, and servicing the regions outside of California—they didn’t share a single set of problems. So the UBT tended to work on departmentwide problems like attendance.

But the single UBT struggled.

 “We basically failed from 2006 to 2009 to do anything,” says Suber Corley, the department’s director, “simply because we were looking at too large a group trying to solve too large a problem.”

So they reorganized. The department now has five UBTs that correspond with employees’ functions.

Setting priorities

The smaller teams set their sites on a number of changes, but they also coordinated with each other on one common goal: to process every application by the 20th of the month.

In their UBT, the mail-room employees decided to look at priorities differently.

“We identified that what we really needed to do was to have a prioritization scheme for every week of the month,” says Victor Romero, CHCO operations manager. He explains that during the first week of January, a recertification application that’s due on April 1 would be low priority in the mail room, whereas a new application—which would need to be processed by January 20 for insurance coverage to begin on February 1—would be high priority. After the 20th, attention moves to the low-priority documents.

The data entry, scanning and enrollment UBTs came up with other solutions, too.

“We instituted several changes in how the application is handled,” says Carl Artis, an enrollment processor team lead and OPEIU Local 29 shop steward. “If we couldn’t process an application, the application was sent back to the customers very early so they could make necessary corrections. We also streamlined our process—there were some things we were doing twice, which wasn’t necessary.”

Artis emphasizes that the changes were developed jointly by frontline workers and managers.

“I have to admit they (the managers) have some really great ideas,” he says, “and they were really able to listen to some great ideas.”

It worked. In October, for the first time in the department’s history, the team was able to process all its new applications by the 20th, so coverage for those applicants could start in November.

“The end result is that poor children did not go without health coverage,” Romero says.

Addressing burnout

In addition to the project to reduce the amount of time it takes to process new applications, the smaller teams have taken on other projects, like reducing burnout among customer service agents who spend all day answering phone calls. They’ve also done charity work together, raising funds to provide school supplies for low-income students at a local high school.

Artis passes on the story of his department’s flourishing UBTs to other members of Local 29.

“I’ve heard some people say, ‘Oh, that’s too much work to take on,’ or, ‘We don’t have the resources we need to address the issue’ or ‘Management would never go for that,’ ” Artis says. “But what I’ve learned is—just try it, and don’t be afraid to fail.”

I have worked at Kaiser Permanente for 33 years, starting as a distribution worker in materials management. Being on the front lines helped me better understand the challenges staff face—and helped me, in my current role, see what it takes to spread and sustain change in a complex organization.

When we launched our first unit-based teams in 2007, I knew they could give our managers and teams a powerful tool for change. But to achieve their full potential, UBTs need the support of leaders at every level. In working with UBTs every day, I have found five practices that can help teams achieve their goals, and have helped me be a more effective leader.

Have patience

I’m not a patient person by nature, and it took a visit to the world-class health care system in Jonkoping, Sweden, for me to see that it takes patience to sustain meaningful change. When you’re solving problems in a team-based workplace, real systemic change takes time. But it also takes hold deeper into the organization.

Really see the work

Spend time with a UBT, or hear teams present their test of change, to understand what they’re working on and how you can support them. There’s no way you can feel the excitement and energy from the team members and not feel proud and motivated by their work.

Spread good work

In Orange County—which has two large hospitals, in Irvine and Anaheim—we expect all teams to continually test and then spread their ideas and successful practices. We call it “One OC” and we talk about it all the time. You’re never going to achieve greatness globally if you don’t spread good work locally.

Provide tools

Early on we formed an Integrated Leaders group of senior labor and management leaders who meet monthly to monitor and assist our 107 UBTs. If a team is struggling, the IL group doesn’t descend on them and try to fix the problem. We provide tools and resources that help the team work through a problem and get results. For instance, we put together a UBT Start-up Toolkit with information on everything from setting up teams to finding training. We’re also looking at toolkits on fishbone diagramming, conducting small tests of change and providing rewards and recognition. And we’re asking how to make it easier for teams to access resources quickly—for instance by identifying go-to people for questions on budgeting, patient satisfaction metrics and so on.

Then, get out of the way

 I have a saying: “Hire great people, give them the coaching and mentoring they need, then get the heck out of their way and let them do what they were hired to do.” I think that works at all levels of the organization, whether or not people are your direct hires. You don’t tell people to make a change or streamline a process without any encouragement or support, but you don’t need to micromanage them either. Delivering great health care is not just a job. It is a calling. Whether you’re a housekeeper preventing infection or a surgeon treating cancer, people’s lives are in our hands. That shared mission drives us to be the best.

What happens when teams truly walk a mile in their patients’ shoes? They often discover their own actions are making that mile a rocky one for patients—and as a result make huge breakthroughs in the way they deliver care.

In the case of South San Francisco’s multidepartmental pre-admission team, observing their processes from the other side of the gurney spurred them to dramatically streamline the pre-surgery and admitting process for patients. With the member at the forefront of their thinking, the team members turned a two-inch-thick packet of confusing, redundant information into a streamlined, one-page checklist. And a funny thing happened—while redesigning the process to help patients, the team improved the way it works.

“Patients would often get confused and weren’t sure what the next step in the process was,” says Brian Tzeng, MD, the Peri-operative Medicine director. “We realized we didn’t have a clear path for the patient to follow.”

Other teams throughout Kaiser Permanente are making similar realizations, framing their performance improvement work by asking the question, “What’s best for the patient?” If a possible solution doesn’t work well for the member and patient, then there’s more brainstorming to be done. These teams are taking the Value Compass to heart—organizing their work not just around the four points but examining what they’re doing from the patient’s perspective.

What does that mean for frontline teams? At the San Diego Medical Center, the Emergency Department sees up to 300 patients every 24 hours. Physicians and staff members are always on the go, delivering on the ultimate bottom line—saved lives. What could be more important? Clinical quality is high; patients are seen in a timely manner and the rate of unscheduled return visits is good.

Yet the results of a recent patient satisfaction survey bothered the team. The department scored well overall, but their patients gave it only 63 percent approval on one question: While you were in the Emergency Department, were you kept informed about how long the treatment would take?